Percutaneous Coronary Intervention (PCI) – Risks & Benefits

Clinical Evidence

In comparison with conservative management (medical treatment without reperfusion therapy), fibrinolytic therapy leads to improved left ventricular systolic function and survival in patients with myocardial infarction associated with either ST-segment elevation or left bundle-branch block. In a pooled analysis of nine large trials, the rate of death at 35 days was 9.6% among patients receiving fibrinolytic therapy, as compared with 11.5% among control subjects.

However, fibrinolytic therapy has several limitations. First, among those presenting with myocardial infarction with ST-segment elevation, some patients (27% in one report) have a contraindication to fibrinolysis. Second, in approximately 15% of patients given fibrinolytic therapy, thrombolysis does not occur. Third, about a quarter of those receiving fibrinolytic therapy have reocclusion of the infarct-related artery within 3 months after the myocardial infarction, with a resultant reinfarction. These limitations are minimized with the use of primary PCI.

In a meta-analysis of 23 randomized, controlled comparisons of primary PCI (involving 3872 patients) and fibrinolytic therapy (3867 patients), the rate of death at 4 to 6 weeks after treatment was significantly lower among those who underwent primary PCI (7% vs. 9%). Rates of nonfatal re-infarction and stroke were also significantly reduced. Most of these trials were performed in high-volume interventional centers by experienced operators with minimal delay after the patient’s arrival. If primary PCI is performed at low-volume venues by less-experienced operators with longer delays between arrival and treatment, such superior outcomes may not be seen.